NEW BEGINNINGS - 2026 RISE INTO YOUR POWER with ELEVATE ON DEMAND Registration

Parent / Guardian Name

First NameLast Name

Athlete name

First NameLast Name

PROGRAM OPTION CHOSEN: OPTION 1, OPTION 2, OPTION 3, OPTION 4

Athlete Birthday & Age

Email for invoicing

example@example.com

Weekly Call Phone Number

Please enter a valid phone number.

Parent Phone Number

Please enter a valid phone number.

Studio / Gym / training facility you currently attend?

City & State of where you train?

Athlete Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

What are your goals with the program?

Athletes strength?

Athletes area they want to improve?

The following days and times are available to request your weekly FaceTime call.

Please list an email address preferred for your invoice to be emailed to. Once your form is received you will be invoiced to this email from the Motivate & Elevate Paypal account.

Parent/Guardian Consent & Release for One-on-One Virtual Coaching Sessions with a Minor
Coach: Rebecca Bass
Program: Motivate & Elevate Coaching by Rebecca – Mindset Empowerment Sessions

Purpose of Sessions

These sessions are designed to provide mindset support, confidence coaching, and personal development strategies for minors using virtual platforms like FaceTime.

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Consent & Acknowledgement

By signing this form, I, the parent/legal guardian of the above-named minor:
    1.    Give permission for my child to participate in one-on-one coaching sessions with Rebecca Bass via FaceTime or a similar video platform.
    2.    Understand that these sessions are for empowerment, growth, and mindset support—not therapy or medical treatment.
    3.    Acknowledge that I may be present or nearby during the session, and I may request a summary of what was discussed.
    4.    Release and hold harmless Rebecca Bass and Motivate & Elevate Coaching from any claims arising from participation in the sessions, to the extent permitted by law.
    5.    Grant permission for session notes to be kept confidential, unless there is a safety concern requiring mandatory reporting.

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Safety & Confidentiality
    •    Rebecca agrees to maintain professional boundaries and to prioritize the minor’s safety and well-being.
    •    No recordings will be made without prior written consent.
    •    Parent/guardian will be notified immediately if any concerns arise regarding the minor’s safety or behavior.

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Photo and Video Release

I, the undersigned parent/legal guardian, grant permission for Rebecca Bass and Motivate & Elevate Coaching to use photographs, video recordings, or screenshots that may include my child during coaching sessions or related activities. These may be used for promotional, marketing, or educational purposes, including but not limited to social media, websites, printed materials, and presentations.

I understand that:
    •    No identifying personal information (e.g., full name, contact details) will be shared without additional written consent.
    •    I may revoke this consent at any time in writing, with the understanding that any materials already produced and shared cannot be retracted.
    •    I am not entitled to any compensation for the use of these materials.

Select one from dropdown to grant permissions.

Signature